For Trans students, no simple remedy

In February, Brown University joined 36 other universities in covering gender confirmation surgery for students on its medical plan. Yale was not among the 36.

Seizing upon an article in The Brown Daily Herald, hosts on “Fox and Friends” told their viewers, “Don’t date anyone from Brown without reviewing medical records.” Although the comment echoes now-disparaged rhetoric on gay and lesbian issues from three decades ago, no apology was ever offered.

The episode, however, revealed something more than the leanings of Fox News. It showed that to most Americans, transgender issues are defined by gender confirmation surgery, which many wrongly believe to be a single procedure, and in what many transgender individuals would consider offensive, referred to it as a “sex change.”

The language of transgender issues is fraught. Is it sex reassignment surgery or gender confirmation surgery? Is it FTM (female-to-male) man or transgender man? Transgender issues, like gay and lesbian issues, lie at the intersection of sexuality, politics and religion. But unlike gay and lesbian issues, transgender issues have stayed in the shadows of national and campus discussion, perhaps because of the size of the transgender population and perhaps because they continue to appear too fraught to broach.

At Yale, policies on gender confirmation surgery remain contradictory. While covered under the faculty medical insurance plan, the procedure remains explicitly excluded from procedures covered by the student plan.

Although the surgeries, of which there are many, can cost anywhere from $7,000 to $50,000, utilization rates, says transgender student Gabe Murchison ’14, would be so low as to make the cost to the University “a drop in the bucket.” Activists, including members of Resource Alliance for Gender Equity, of which Murchison is a part, are pushing the University to cover the procedures, although major change in the near future appears unlikely. In covering the procedures for faculty and most employees, Murchison says, Yale Health has already stated that they are medically necessary for transgender individuals. It is unclear, then, why they remain excluded from the student plan.

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As prospective Yalies pore over admissions materials throughout April, few are likely to make their way onto the Yale Health website to download the Student Handbook, which describes, point by point, what is and what is not covered by Yale’s student health plan. But for the University’s transgender students, a small minority that receives even smaller consideration, the policies contained in the handbook make all the difference in how they live their lives and how they are regarded by the University as an institution.

Public narratives emphasis gender confirmation surgery over any other medical treatment sought by transgender individuals. But hormone therapy, in part because of its low cost and in part because of the ease of treatment, plays a role in transitions from one gender to another more than any surgery. The University recently altered the student plan to cover hormone therapy — in which individuals born as one gender take hormones associated with the other — which Murchison says is a major step forward in providing necessary medical care.

The change in the University’s policy on hormone therapy is the sum of many small pushes, by transgender and gender-conforming students alike, the kinds of small pushes that are the only way for transgender students to receive necessary care in the labyrinthine Yale Health bureaucracy.

Students’ experiences reflect a frustratingly complex system that poses significant obstacles to transgender students seeking health care specific to their transition from one gender to another. When Jake Hodge ’15 tried to access gender-specific care at Yale Health, including endocrinology, which would prescribe appropriate hormones, he found the experience “hellish,” a not-uncommon sentiment.

“I was given contradictory information from multiple departments, my psychiatric and endocrine referral papers were lost in the system, and my care was delayed by almost a month so that an ‘interdisciplinary board’ within the hospital could approve it, which I was outright informed by my physician as a completely unnecessary protocol,” Hodge said of his attempt to see an endocrinologist.

Once Hodge made it through the bureaucracy, though, he found the staff at Yale Health helpful and sensitive.

“After jumping through an absurd number of arbitrary hoops, the Endocrinology Department itself has been nothing but supportive and competent,” Hodge said.

In cultivating a good relationship with an endocrinologist, Hodge cultivated the same thing that defines all good relationships between patients and doctors: trust. The ability to trust health care providers, several transgender students say, is rooted in cultural competency: In this case, the ability to knowingly and sensitively address, or at times not address, a student’s gender status.

But such competency can be elusive at Yale Health.

“Some providers know enough to do a good job, while … others clearly do not. I have heard of more bad experiences than explicitly good ones,” Murchison says.

Transgender students describe experiences of doctors dragging their gender status into otherwise unrelated medical conditions, doctors appearing visibly uncomfortable or stumbling over how to appropriately refer to a student.

Angel Collie DIV ’14, who identifies as a man, recollected a visit to Yale Health in which doctors continued to use female pronouns, even though he identified as a man. It took speaking to a younger nurse, whom Collie felt to be more likely to accept his gender identity, to slowly disseminate the word that male pronouns were correct, after which Collie said doctors exercised appropriate sensitivity in discussing his gender.

“On file, it must be female, so that’s what they assume,” Collie said.

At a personal level, expanding cultural competency, at times through as little as a conversation, appears within reach. Yet there remain institutional barriers that make widespread change difficult.

Paperwork poses a significant problem. On the intake form, three options are offered: male, female and transgender, which, Murchison says, betrays an underlying misunderstanding of what being transgender is.

“The term transgender describes the fact that they have moved from one gender to another, not their gender itself. Thus, making male, female and transgender mutually exclusive options makes little sense,” Murchison says, suggesting that a better option would be to ask if a student is transgender in a separate question.

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There is no silver bullet for a lack of cultural competency, but a combination of education and generational turnover might do the trick. Collie and others interviewed believe the best way to improve cultural competency is through continuing education for staff at Yale Health, adding that the University needs to create incentives for its employees to actively pursue more knowledge on the topic.

“Anyone who’s going to be coming in contact with trans folks should be educated about what that means,” Collie said.

Any organized push for that kind of continuing education on transgender issues among medical practitioners will be part of a long-term battle. Yet any current or future efforts will find themselves closer to the beginning of a movement’s history than the end. At Yale, Murchison says, there is little to no student organizational history around transgender issues, beyond Trans Week, which has brought artists and speakers to campus to discuss the issue for the past 10 years.

The first attempts to actually change University policy to reflect greater sensitivity have an even shorter history.

In 2006, the Yale College Council pushed the administration to include “gender expression” in its nondiscrimination clause, after a transsexual dining hall worker sued the University for harassment. And three years later, non-transgender and transgender alike proposed that the University permit mixed-gender housing. Like all institutions, Yale moves at its own pace: In 2011, the University allowed seniors to live in mixed-gender suites, and then, in 2012, the policy was expanded to cover juniors.

Today, some activists on campus are asking Yale to liberalize even further, and extend the same option to sophomores.

But the trajectory of transgender activism at Yale runs alongside — and at times separately from — the history of transgender activism in the nation at large, which has sought to address issues faced by few, if any Yale students. America’s transgender population is marked by disproportionately high rates of homelessness, violence and suicide. According to a 2010 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 41 percent of transgender individuals have attempted suicide. In addition, a 2010 study by the Center for American Progress put the percent of homeless and at-risk youth who identify as gay, lesbian or transgender at 40 percent.

Reconciling what could easily be described as two different worlds, the one inside the University and the one beyond it, is no easy task for transgender activists, Murchison says. In one sense, the knowledge that transgender individuals, some as nearby as downtown New Haven, are frequent victims of homelessness and targets of violence, makes fighting for insurance coverage appear relatively trivial.

But at the same time, perhaps those changes that within the scope of a University are small, and within the scope of a nation even smaller, will together constitute small pushes on a grand scale. And perhaps those pushes will yield larger results — precisely the way Hodge’s push to receive the medical care he needed at Yale Health did.